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Dorsiflexion Goniometry
Dorsiflexion Goniometry is a form of physical therapy and rehabilitation used to assess a patient’s range of motion in the ankle joint. The assessment measures the amount of dorsiflexion available and is performed using a specialized goniometer that measures and records the angle of movement. This type of assessment helps to identify any deficits in mobility and allows the therapist to create an individualized treatment plan to help improve the patient’s range of motion.
Transcript
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This is Brent of the Brookbush Institute
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at the Independent Training Spot. Today
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we're going over goniometric assessment, specifically dorsiflexion. So
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we've been talking about this large overhead squat assessment which is a
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great postural assessment, gives you an indication of the compensation pattern
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and all of the joints involved in the dysfunction that you're looking at. But
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now you need to get a little bit more specific, we need to look joint for joint
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and see where we are restricted, and if possible put some objective data to that
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restriction, that's a number that we can actually show progress over time. I'm
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going to have my friend Mike Tierney come out from metropolitan fitness, he's going
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to help me demonstrate. He was nice enough today to show off his legs and
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get taped up. So dorsiflexion right, dorsiflexion is this joint motion here.
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Anytime we do goniometric assessment they're going to talk about making two
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lines, one for your stabilization arm which is the arm that attaches to the
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protractor of the goniometer, and one for your movement arm. So this is
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just, there's degrees listed here, here's my movement arm, pivot point,
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stabilization arm. You can see with Mike to make things a little easier for the
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camera I've gone ahead and taken big orange pieces of rock tape, and outlined
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the lines that we're going to use for dorsiflexion goniometric assessment.
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Norkin and White, Norkin and Whites is kind of the the standard text
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for goniometric assessment, they talk about the stabilization arm going
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through a line, an imaginary line that we draw from fibular head to lateral
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malleolus, and so that's that's what I've outlined here with the rock tape, and
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then they're going to talk about the movement arm being parallel to the fifth
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metatarsal. So essentially what we're measuring is
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how many degrees do we see of movement between these two lines. Now one of the
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weird things about goniometric assessment is it's in degrees of motion.
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So despite this being nearly a 90-degree angle, since this is neutral dorsiflexion
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this is zero. Alright normal dorsiflexion is between 15 and 20
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degrees, all right so we want to see 15 to 20 degrees of motion. The weird thing
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about ankle dorsiflexion range of motion is because these muscles are so strong
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right, they're used to the Mikes entire body weight. Every time he takes a step,
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rather than passive range of motion which he probably, you know we don't have
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that much passive range of motion at the ankle. We do active assistive range of
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motion so that we overcome some of this muscular restriction. So I'm going to have
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Mike actually pull up on this assessment, and then I'm going to give them a little
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over pressure almost like I was simulating the ground during gait. So I'm
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going to have Mike lay back in a supine, make sure they're not sitting up on you as
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that can create some neural restriction. I'm going to have him scoot down just a
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little bit for me, so those ankles hanging off. I'm going to put my
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stabilization arm over the line I was talking about, fibular head to lateral
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malleolus. My pivot point, in Norkin and White they talk about being over the
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lateral malleolus, and then this movement arm is going to be parallel to this line
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here. So I'm going to have Mike go ahead and pull up for me dorsiflex. Be very
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careful when you guys do this that you're paying attention to how he
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dorsiflexes, if he dorsiflexes and everts, you're going to get a
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different number and that's not going to be an accurate assessment of pure
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dorsiflexion. So you can either kind of assess the talus and make sure that
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it's even on both fingers here, by palpating the talar neck, or you can
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kind of monitor that second and third toe, but make sure as he's pulling up
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there it's nice and pure. I'm going to go ahead and put movement arm
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over that line, pivot point lateral malleolus. I'm going to give them a
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little over pressure, make sure he's pulling up. I'm going to look back here,
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make sure my lines are parallel, and I get 18 degrees of dorsiflexion. Mike's
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got some good dorsiflexion. Alright so one more time guys, I'm actually going to
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show you a little trick, rather than going parallel to this line it's
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actually easier and it doesn't change your measurement at all to move your
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goniometer back, keep this line the same but pretend it extends a little
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farther. So it's still fibular head the lateral malleolus, but keep it going put
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your pivot point on the fifth metatarsal, and now what you can do is you almost
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like free up a hand, because now you can kind of just push the goniometer
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the movement arm and his foot into over pressure, at the same time make
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sure everything aligns. Alright the other thing I wouldn't do is sit in this
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position here, I would be sitting on the other side and once again I get 18
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degrees. Hopefully you guys can see how that would make it a little easier by
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just moving that back, I got one hand back because this hand was able to push
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both of the movement arm and his foot. Now like I said I wouldn't be here on
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this assessment, I would be here, I just didn't want to turn my back to the
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camera and I wanted you guys to be able to see what I was doing, thank you Mike.
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Now the big question with goniometry is what do we do with it. It's very
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important when we choose our assessments that they have purpose. All assessments
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if I were to summarize are going to kind of fall into two categories, there either
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diagnostic assessments, or assessments that clear our patients and clients for
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intervention. That is is that intervention appropriate, or do they need
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to be referred out. Or we have assessments like goniometry which
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hopefully are going to have an impact on our exercise and intervention selection.
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In order for dorsiflexion goniometry to have an impact on our intervention
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we need to know what restricts dorsiflexion, and that's where this graph
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behind us comes in. So we'll start with knowing what we're looking at, we're
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looking at active assisted range of motion 15 to 20 degrees. Mike had 17
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degrees, 18 degrees, So this might not be his biggest problem. We then look at end
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feel which for this particular measurement should be firm, that is
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you're going to feel not a hard stop like rock on rock, but more like a
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leather strap. It's going to it's going to be soft soft soft soft soft and then
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it's going to firm up pretty good, and there's going to be just the little
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gives, but not too much. Right and that's kind of a a muscular end feel because
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the primary restrictors for dorsiflexion are muscles, gastroc, soleus and fibularis.
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This probably kind of makes sense to you guys right, our commonly
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overactive plantarflexors are gastroc, soleus, and fibularis, that would make
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sense that they restrict dorsiflexion in a lot of individuals. So how would that
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impact my intervention, maybe I'm going to release and lengthen these guys,
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release and stretch these guys. Well we can take this many many many steps
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further, and this is where your knowledge of functional anatomy comes in. Let's say
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I didn't get a firm end feel but I got a hard end feel, a bone on bone right,
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that's that's more of a joint end feel, and I'm going to start thinking maybe
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there's something going on with this talus right, because tibiotalar
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dysfunction as well as distal tib fib dysfunction can also play a role in
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dorsiflexion restriction. Maybe I check this out, or maybe I do a
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technique like my ankle mobilization and I still don't get back to 15 to 20
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degrees of dorsiflexion. Well then maybe I start looking at fascial components. I
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know my guys out there doing instrument assisted soft
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tissue mobilization, or those you guys doing pin and stretch, those fascially
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directed techniques, well you need to know what fascial structures could
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potentially restrict dorsiflexion, being the posterior capsule, posterior crural
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fascia, my posterior talofibula ligament, my calcaneal fibula ligament or my
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posterior halal tibial ligament. I will say that it's pretty rare but it might
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be worth knowing what nerve could restrict dorsiflexion as well. I think in
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this particular position with Mike's hip in neutral it'd be pretty rare that we
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would start getting tibial or sciatic nerve issues, and if we did we would
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probably want to do further testing to figure out exactly how it's restricted.
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But you guys can see here this graph is going to keep coming back in every
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goniometric assessment video I do. What are the muscles, joints, fascial and neural
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structures that could restrict that joint motion, and my whole intent is to
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help direct how am I going to make this better. That's it. I will show further
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assessments so that this board of a bunch of things, becomes maybe one or two
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things, or maybe just a few things to go ahead and address. But starting here at
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the very least, even if you didn't know any further assessments. Look at all of
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the potential options you have to getting somebody back to optimal range
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of motion. So I'm going to bring Mike back out here for one more practice of
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this dorsiflexion range of motion.
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Just a quick recap, he's going to lay back in supine position, his knee in
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soft extension. I'm going to draw that line from fibular head to lateral
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malleolus. You guys know I like to move the goniometer down so that my
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stabilization arm is still through that line, but my pivot point is now on the
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fifth metatarsal, and then I'm going to have him pull up, make sure his
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dorsiflexion is pure. I'm going to realign my goniometer, i'm going to give
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them a little over pressure, and i get 18 degrees. I hope that helps you not only
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do goniometric assessment, but use goniometric assessment. I look forward to
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hearing about your outcomes.
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